Hargreaves St. Medical Practice - Bendigo
New Patient Form

Patient Details

Next of Kin

Emergency Contact

Consent & Signature

PATIENT PRIVACY INFORMATION: To provide a high standard of care and as an accredited practice we need to record basic personal and health information. This information is treated with the strictest of confidence and may only be divulged to a third party with your consent, unless required by law or in an emergency situation. The staff members of HSM are subject to strict confidentiality obligations. De-identified health information may be used by third parties for quality improvement or research projects. You may opt out of this at any time by informing reception or your doctor. Misleading or inaccurate information may affect our ability to provide the best health outcome for you. HSM uses SMS contact for appointment reminders & to recall patients for outstanding test results. We send letters if you cannot be contacted or do not consent to SMS messages. You may opt out of electronic communications at any time. Please refer to our Privacy Policy found on our website or ask reception for more details. You may opt out of email or SMS communications at any time by notifying us.


Referral (Optional)